Saturday, November 16, 2013

Messiness isn't the problem

Okay so I was listening to Monica Crowley today. She made an interesting comment about the mess that is Obamacare, at least now as people scramble to get on the website to try to apply so many problems. She said "this is what socialism is like. Of course it's a mess. Whatever you try to impose socialism, it's always a mess."  The statement told  me   two things about Monica Crowley. First off, she was nowhere near Leningrad or Moscow in the spring of 1992. I know this because she would've remembered the messiness it comes with unmanteling socialism.  She doesn't remember seeing cars full of  worthless rubles lying in the field rusting away. She doesn't remember people protesting on the street because they were learning that their pensions, guaranteed to them since babyhood, no longer existed.  She does not remember the crime wave filling  the vaccuum that communism left behind.

Secondly, she is very naive about our health system, which is about as non-socialist as Lenin dressing up as Saul Alinsky at a party hosted by Lillian Helmann and Kate Hepburn on halloween.

Even completely private health insurance plans change the economic relationship between patients and care in a way that distorts the value of services rendered, and that artificially or temporarily  protects buyers from experiencing the cost.  I say "artificially" because even though the insurance company may pay the bill, the patient is saddled with increased costs in the form of deductibles, copays, or in the worst cases, being dropped from the plan.

And I say "temporarily" because it seems like the contemporary system was a house of cards, particularly when the government stepped in to forbid companies from avoiding the sickest of patients in order to decrease their risk.  An insurance company can no more survive if required to "insure" everyone than a car insurance company can afford to give as cheap and comprehensive policy to riskier drivers as they can to statistically safer drivers.  But insurance had another self-destruct command along with it:  higher prices for care.

This was more clearly a problem after Medicare was enacted in 1967.  Medicare has famously lax means for policing itself.  I've talked a little about my work before, but I work in a hospital identifying and getting insurance authorization of people needing inpatient psychiatric care.  Or I get authorization if the payor (insurance or whatever charitable or public fund is available) demands it.  This is about 99% of the time.  The one insurance that NEVER and I mean NEVER requires precert is Medicare.   Like the honey badger, Medicare don't care.   Medicare recipients may have a secondary insurance that I need to call and get authorization, but the Medicare itself is uninterested in whether the patient really needs the and because it is a vehicle of politics and not of risk, decisions are made about it in order to scratch backs, not save money or ensure good care.  This helped drive prices up for all insurances.

If health care was still delivered on an individual basis, that is, with the practitioner and patient or family bartering for the best price, one that gave the practitioner a fair reimbursement but that the patient could afford, I can't help thinking things would be better.